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Membership Form

Or you can join up or renew your membership online by filling in the form below. The system uses Paypal but will happily accept normal credit / debit cards without the need for a Paypal account.

Fields marked (*) are required, but as much information as possible is helpful. Your information is never shared with third-parties without your express consent.

Type:*New MembershipMembership Renewal

Name:*

Address:

Telephone:

Email:*

Category:* Parent of Child with Dyspraxia €30 Adult with Dyspraxia €30 Professional €35 Other €30

Do you require a receipt?

Adult

Date of Birth:

Age(s) at Diagnosis:

Any other relevant information:

Parent

Please tell us about your child

BoyGirl

Name of Child/Children:

School(s) Attending:

Date of Birth:

Age(s) at Diagnosis:

Speech Difficulties:

What services are you currently receiving?:

Any other relevant information:

Professional

Your Profession:

Age group of children you are in contact with:

Additional Donation:
€
If you would like to make an additional donation to the association we would very much welcome your contribution (please use whole numbers only, anything after a decimal point will be disregarded)